Revision 25-1; Effective Sept. 1, 2025

The case manager is responsible for verifying the person’s eligibility for the CLASS program by ensuring the following criteria are met.

• The person is financially eligible for Medicaid because the person receives Supplemental Security Income (SSI) cash benefits or is determined by HHS to be financially eligible for Medicaid.
• The person has been diagnosed before 22 with a related condition as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions.
• The person has a qualifying adaptive behavior level of II, III, or IV such as moderate to extreme deficits in adaptive behavior obtained by administering a standardized assessment of adaptive behavior.
• The person demonstrates a need for CFC PAS/HAB;   The person requires and receives:
  • at least one CLASS service per month; and
  • one CLASS service per year (monthly monitoring of services by a case manager meets this annual requirement).
• The person has an Individual Plan of Care (IPC) cost for CLASS services at or below $149,774.
• The person is not enrolled in another Medicaid waiver program.
• The person resides in his or her own home or family home.

The CMA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the person is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits. If the CMA receives notice of an person's impending loss of Medicaid eligibility, the CMA must work proactively with the person or legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For people who lose Medicaid eligibility, the CMA must offer direct assistance to the person or LAR as necessary to help the person re-establish eligibility. The CMA must follow up with the person or LAR at least every two weeks and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the person is terminated from the CLASS program.

Program services may be terminated if the person does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) Section 45.406. Refer to 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services.